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Dr.

ADEEL AHMED WAHEED


HOUSE OFFICER M-4

ECG Basics

Electrocardiography (ECG or EKG [from the German Elektrokardiogramm]) is a transthoracic (across the thorax or chest) interpretation of the electrical activity of the heart over a period of time, as detected by electrodes attached to the outer surface of the skin and recorded by a device external to the body.
The recording produced by this noninvasive procedure is termed an electrocardiogram (also ECG or EKG).

Impulse Conduction & the ECG


Sinoatrial node AV node Bundle of His Bundle Branches Purkinje fibers

The PQRST

P wave Atrial depolarization

QRS Ventricular depolarization

T wave - Ventricular repolarization

The PR Interval
Atrial depolarization + delay in AV junction
(AV node/Bundle of His)

(delay allows time for the atria to contract before the ventricles contract)

The ECG Paper

Horizontally

One small box - 0.04 s One large box - 0.20 s One large box - 0.5 mV

Vertically

The ECG Paper (cont)


3 sec 3 sec

Every 3 seconds (15 large boxes) is marked by a vertical line. This helps when calculating the heart rate. NOTE: the following strips are not marked but all are 6 seconds long.

Rhythm Analysis

Step Step Step Step Step

1: 2: 3: 4: 5:

Calculate rate. Determine regularity. Assess the P waves. Determine PR interval. Determine QRS duration.

Step 1: Calculate Rate


3 sec 3 sec

Option 1

Count the # of R waves in a 6 second rhythm strip, then multiply by 10.

Interpretation? 9 x 10 = 90 bpm

Step 1: Calculate Rate


R wave

Option 2

Find a R wave that lands on a bold line. Count the # of large boxes to the next R wave. If the second R wave is 1 large box away the rate is 300, 2 boxes - 150, 3 boxes 100, 4 boxes - 75, etc. (cont)

Step 1: Calculate Rate


3 1 1 0 5 0 7 6 5 0 0 0 5 0 0

Option 2 (cont)

Memorize the sequence: 300 - 150 - 100 - 75 - 60 - 50

Interpretation?

Approx. 1 box less than 100 = 95 bpm

Step 2: Determine regularity


R R

Look at the R-R distances (using a caliper or markings on a pen or paper). Regular (are they equidistant apart)? Occasionally irregular? Regularly irregular? Irregularly irregular?

Interpretation?

Regular

Step 3: Assess the P waves

Are there P waves? Do the P waves all look alike? Do the P waves occur at a regular rate? Is there one P wave before each QRS? Interpretation? Normal P waves with 1 P wave for every QRS

Step 4: Determine PR interval

Normal: 0.12 - 0.20 seconds. (3 - 5 boxes)

Interpretation?

0.12 seconds

Step 5: QRS duration

Normal: 0.04 - 0.12 seconds. (1 - 3 boxes)

Interpretation?

0.08 seconds

Rhythm Summary

Rate Regularity P waves PR interval QRS duration Interpretation?

90-95 bpm regular normal 0.12 s 0.08 s

Normal Sinus Rhythm

Normal Sinus Rhythm (NSR)

Etiology: the electrical impulse is formed in the SA node and conducted normally. This is the normal rhythm of the heart; other rhythms that do not conduct via the typical pathway are called arrhythmias.

NSR Parameters

Rate Regularity P waves PR interval QRS duration

60 - 100 bpm regular normal 0.12 - 0.20 s 0.04 - 0.12 s

Any deviation from above is sinus tachycardia, sinus bradycardia or an arrhythmia

AV Nodal Blocks

1st Degree AV Block


2nd Degree AV Block, Type I 2nd Degree AV Block, Type II 3rd Degree AV Block

Rhythm #1

Rate? Regularity? P waves? PR interval? QRS duration?

60 bpm regular normal 0.36 s 0.08 s

Interpretation? 1st Degree AV Block

1st Degree AV Block


Deviation from NSR

PR Interval

> 0.20 s

1st Degree AV Block

Etiology: Prolonged conduction delay in the AV node or Bundle of His.

Rhythm #2

Rate? Regularity? P waves? PR interval? QRS duration?

50 bpm regularly irregular nl, but 4th no QRS lengthens 0.08 s

Interpretation? 2nd Degree AV Block, Type I (Wenckebach phenomenon)

2nd Degree AV Block, Type I


Deviation from NSR

PR interval progressively lengthens, then the impulse is completely blocked (P wave not followed by QRS).

2nd Degree AV Block, Type I

Etiology: Each successive atrial impulse encounters a longer and longer delay in the AV node until one impulse (usually the 3rd or 4th) fails to make it through the AV node.

Rhythm #3

Rate? Regularity? P waves? PR interval? QRS duration?

40 bpm regular nl, 2 of 3 no QRS 0.14 s 0.08 s

Interpretation? 2nd Degree AV Block, Type II

2nd Degree AV Block, Type II


Deviation from NSR

Occasional P waves are completely blocked (P wave not followed by QRS).

2nd Degree AV Block, Type II

Etiology: Conduction is all or nothing (no prolongation of PR interval); typically block occurs in the Bundle of His.

Rhythm #4

Rate? Regularity? P waves? PR interval? QRS duration?

40 bpm regular no relation to QRS none wide (> 0.12 s)

Interpretation? 3rd Degree AV Block

3rd Degree AV Block


Deviation from NSR

The P waves are completely blocked in the AV junction; QRS complexes originate independently from below the junction.

3rd Degree AV Block

Etiology: There is complete block of conduction in the AV junction, so the atria and ventricles form impulses independently of each other. Without impulses from the atria, the ventricles own intrinsic pacemaker kicks in at around 30 45 beats/minute.

When an impulse originates in a ventricle, conduction through the ventricles will be inefficient and the QRS will be wide and bizarre.

Axis
Axis refers to the mean QRS axis (or vector) during ventricular depolarization. As you recall when the ventricles depolarize (in a normal heart) the direction of current flows leftward and downward because most of the ventricular mass is in the left ventricle. We like to know the QRS axis because an abnormal axis can suggest disease such as pulmonary hypertension from a pulmonary embolism.

We can quickly determine whether the QRS axis is normal by looking at leads I and II.
QRS negative (R < Q+S)

If the QRS complex is overall positive (R > Q+S) in leads I and II, the QRS axis is normal. In this ECG what leads have QRS complexes that are negative? equivocal?
QRS equivocal (R = Q+S)

How do we know the axis is normal when the QRS complexes are positive in leads I and II?

The answer lies in the fact that each frontal lead corresponds to a location on the circle.
Limb leads

I = +0o
II = +60o III = +120o Augmented leads 180o

-90o -120o -60o -30o 0o 30o 120o 60o

avR -150o

avL I I

avL = -30o
avF = +90o avR = -150
o

150o 90o

III

II II

avF

The normal QRS axis falls between -30o and +90o because ventricular depolarization is leftward and downward. Left axis deviation occurs when the axis falls between -30o and 90o. Right axis deviation occurs when the axis falls between +90o and +150o. Right superior axis deviation occurs when the axis falls between between +150o and -90o.
QRS Complexes

A quick way to determine the QRS axis is to look at the QRS complexes in leads I and II.

I + + -

II + +

Axis normal left axis deviation right axis deviation

right superior axis deviation

Acute Myocardial Infarction

The 12-Lead ECG


The 12-Lead ECG sees the heart from 12 different views. Therefore, the 12-Lead ECG helps you see what is happening in different portions of the heart.

The 12-Leads
The 12-leads include:
3 Limb leads (I, II, III) 3 Augmented leads (aVR, aVL, aVF) 6 Precordial leads (V1- V6)

Views of the Heart


Some leads get a good view of the: Anterior portion of the heart
Lateral portion of the heart

Inferior portion of the heart

ST Elevation
One way to diagnose an acute MI is to look for elevation of the ST segment.

ST Elevation (cont)
Elevation of the ST segment (greater than 1 small box) in 2 leads is consistent with a myocardial infarction.

Anterior View of the Heart


The anterior portion of the heart is best viewed using leads V1- V4.

Anterior Myocardial Infarction


If you see changes in leads V1 - V4 that are consistent with a myocardial infarction, you can conclude that it is an anterior wall myocardial infarction.

Putting it all Together


Do you think this person is having a myocardial infarction. If so, where?

Interpretation
Yes, this person is having an acute anterior wall myocardial infarction.

Other MI Locations
First, take a look again at this picture of the heart.

Lateral portion of the heart

Anterior portion of the heart

Inferior portion of the heart

Other MI Locations
The limb and augmented leads see electrical activity moving inferiorly (II, III and aVF), to the left (I, aVL) and to the right (aVR). Whereas, the precordial leads see electrical activity in the posterior to anterior direction.

Anterior MI
The anterior portion of the heart is best viewed using leads V1- V4.
Precordial Leads

Lateral MI
Lateral portion of the heart is best viewed
Leads I, aVL, and V5- V6

Inferior MI
For inferior portion of the heart
Leads II, III and aVF

Putting it all Together


Now, where do you think this person is having a myocardial infarction?

Inferior Wall MI
This is an inferior MI. Note the ST elevation in leads II, III and aVF.

Putting it all Together


How about now?

Anterolateral MI
This persons MI involves both the anterior wall (V2-V4) and the lateral wall (V5-V6, I, and aVL)!

ST Elevation and non-ST Elevation MIs

ST Elevation and non-ST Elevation MIs

When myocardial blood supply is abruptly reduced or cut off to a region of the heart, a sequence of injurious events occur beginning with ischemia (inadequate tissue perfusion), followed by necrosis (infarction), and eventual fibrosis (scarring) if the blood supply isn't restored in an appropriate period of time. The ECG changes over time with each of these events

ECG Changes
Ways the ECG can change include:
ST elevation & depression

T-waves peaked Appearance of pathologic Q-waves flattened inverted

ECG Changes & the Evolving MI


There are two distinct patterns of ECG change depending if the infarction is:
Non-ST Elevation

ST Elevation

ST Elevation (Transmural or Q-wave), or Non-ST Elevation (Subendocardial or non-Q-wave)

ST Elevation Infarction
The ECG changes seen with a ST elevation infarction are:

Before injury Normal ECG Ischemia Infarction Fibrosis

ST depression, peaked T-waves, then T-wave inversion


ST elevation & appearance of Q-waves ST segments and T-waves return to normal, but Q-waves persist

ST Elevation Infarction
Heres a diagram depicting an evolving infarction:
A. Normal ECG prior to MI B. Ischemia from coronary artery occlusion results in ST depression (not shown) and peaked T-waves C. Infarction from ongoing ischemia results in marked ST elevation

D/E. Ongoing infarction with appearance of pathologic Q-waves and T-wave inversion
F. Fibrosis (months later) with persistent Qwaves, but normal ST segment and Twaves

ST Elevation Infarction
Heres an ECG of an inferior MI:
Look at the inferior leads (II, III, aVF). Question: What ECG changes do you see?

ST elevation and Q-waves What is the rhythm? Atrial fibrillation (irregularly irregular with narrow QRS)!

Non-ST Elevation Infarction


The ECG changes seen with a non-ST elevation infarction are:

Before injury Normal ECG Ischemia Infarction Fibrosis

ST depression & T-wave inversion


ST depression & T-wave inversion ST returns to baseline, but T-wave inversion persists

When analyzing a 12-lead ECG for evidence of an infarction you want to look for the following:

Abnormal Q waves ST elevation or depression Peaked, flat or inverted T waves ST elevation (or depression) of 1 mm in 2 or more contiguous leads is consistent with an AMI There are ST elevation (Q-wave) and non-ST elevation (non-Q wave) MIs

Bundle Branch Blocks

Normal Impulse Conduction


Sinoatrial node AV node Bundle of His Bundle Branches Purkinje fibers

Bundle Branch Blocks


So, depolarization of the Bundle Branches and Purkinje fibers are seen as the QRS complex on the ECG. Therefore, a conduction block of the Bundle Branches would be reflected as a change in the QRS complex.

Right BBB

Bundle Branch Blocks


With Bundle Branch Blocks you will see two changes on the ECG.
1. 2.

QRS complex widens (> 0.12 sec). QRS morphology changes (varies depending on ECG lead, and if it is a right vs. left bundle branch block).

Bundle Branch Blocks


Why does the QRS complex widen? When the conduction pathway is blocked it will take longer for the electrical signal to pass throughout the ventricles.

Right Bundle Branch Blocks


What QRS morphology is characteristic? For RBBB the wide QRS complex assumes a unique, virtually diagnostic shape in those leads overlying the right ventricle (V1 and V2). V1

Rabbit Ears

Left Bundle Branch Blocks


LBBB is best seen inV6,where there is a broad complex with a notched top,which resembles the letterM

Normal

In this step of the 12-lead ECG analysis, we use the ECG to determine if any of the 4 chambers of the heart are enlarged or hypertrophied. We want to determine if there are any of the following:

Right atrial enlargement (RAE) Left atrial enlargement (LAE) Right ventricular hypertrophy (RVH) Left ventricular hypertrophy (LVH)

Right atrial enlargement

Take a look at this ECG. What do you notice about the P waves?

The P waves are tall, especially in leads II, III and avF.

Right atrial enlargement

To diagnose RAE you can use the following criteria:


II V1 or V2

P > 2.5 mm, or P > 1.5 mm

> 1 boxes (in height)

> 2 boxes (in height)

Remember 1 small box in height = 1 mm

A cause of RAE is RVH from pulmonary hypertension.

Left atrial enlargement

Take a look at this ECG. What do you notice about the P waves?

Notched

Negative deflection

The P waves in lead II are notched and in lead V1 they have a deep and wide negative component.

Left atrial enlargement

To diagnose LAE you can use the following criteria:


II V1

> 0.04 s (1 box) between notched peaks, or Neg. deflection > 1 box wide x 1 box deep

Normal

LAE

A common cause of LAE is LVH from hypertension.

Right ventricular hypertrophy

Take a look at this ECG. What do you notice about the axis and QRS complexes over the right ventricle (V1, V2)?

There is right axis deviation (negative in I, positive in II) and there are tall R waves in V1, V2.

Right ventricular hypertrophy


Compare the R waves in V1, V2 from a normal ECG and one from a person with RVH. Notice the R wave is normally small in V1, V2 because the right ventricle does not have a lot of muscle mass. But in the hypertrophied right ventricle the R wave is tall in V1, V2.

Normal

RVH

Right ventricular hypertrophy

To diagnose RVH you can use the following criteria:


V1

Right axis deviation, and R wave > 7mm tall

A common cause of RVH is left heart failure.

Left ventricular hypertrophy

Take a look at this ECG. What do you notice about the axis and QRS complexes over the left ventricle (V5, V6) and right ventricle (V1, V2)?

The deep S waves seen in the leads over the right ventricle are created because the heart is depolarizing left, superior and posterior (away from leads V1, V2).

There is left axis deviation (positive in I, negative in II) and there are tall R waves in V5, V6 and deep S waves in V1, V2.

Left ventricular hypertrophy

To diagnose LVH you can use the following criteria*:


R in V5 (or V6) + S in V1 (or V2) > 35 mm, or avL R > 13 mm

S = 13 mm

* There are several other criteria for the diagnosis of LVH.

R = 25 mm

A common cause of LVH is hypertension.

THANK YOU

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